The Compliance Team

Patient Satisfaction Survey — Community Pharmacy

Items below designated with an asterisk ( *) are required.
Requested By:	Edward Arabov at
Your Name:	First: Last:
Your Phone #:	Use the following format (XXX) XXX-XXXX
New or Existing Patient:*	New Existing
Service:*
Make or Serial # (as applicable):
Date of Service:*	(mm/dd/yyyy format)
Pharmacist or Pharmacy Tech Name: Unknown

	Access, Delivery and Service	Yes	No	N/A
1	Responses to questions, concerns were addressed in a timely manner.
2	Service friendly, prompt and courteous.
3	Satisfied with the time spent with the Pharmacist.
4	Did Pharmacist / Staff request info on other medications currently prescribed.
5	Satisfied with medication counseling / instructions provided by the Pharmacist.
6	Satisfied with the length of time for prescription processing.
7	Received info on Patient Rights and Responsibilities.
8	Satisfied with the service. Would recommend to others.

COMMENTS:

We greatly appreciate your input. We use patient satisfaction survey reports to help us improve our day-to-day services. Please take an extra minute to provide details for your survey responses in the box below.